Cancer continues to be the 2nd most common cause of death in the United States. New treatments for different types of malignancies are developed every year, slowly and incrementally improving our ability to treat many forms of cancer. In young men of reproductive age, the two most common forms of malignancy are testicular cancer followed by lymphoma. Increasingly effective treatments have led to more of these men becoming cancer survivors and considering the option of having children later in life.
Unfortunately, having a malignancy can have a negative impact on sperm numbers and quality, and the cancer treatments themselves can further damage a man’s fertility potential. At the time of initial diagnosis of a malignancy, many men already have abnormalities in their semen parameters, and some have no sperm whatsoever (called “azoospermia”). These pre-treatment male fertility abnormalities are felt to be caused by both the stress on the body caused by the malignancy, as well as the immunologic response of the body attempting to fight off the cancer.
Many effective cancer treatments have been developed, including chemotherapy and radiation therapy. These types of therapies target rapidly dividing cells, which includes most malignant cell types. Unfortunately, a number of normal body cells also divide rapidly, and can therefore be damaged or killed by these treatments. The sperm precursor (germ) cells are among these rapidly dividing cells that can be damaged by cancer therapies.
The damage to a man’s fertility with malignancies and their treatments can be impacted in two ways:
1) Decreased semen parameters and an ability to establish a pregnancy
2) Increased sperm DNA damage (called “aneuploidy”) which can potentially increase the rate of miscarriage, birth defects, and other health problems in the child.
Earlier this year, the scientific journal Fertility and Sterility published 2 articles by a medical team in France looking at the fertility of men who are testicular cancer and lymphoma survivors. The majority of men in both of these studies did eventually have a return of fairly good semen parameters by 12-24 months. However, the quality of these semen parameters did not necessarily correlate with the presence of elevated levels of sperm aneuploidy.
In regards to sperm aneuploidy and testicular cancer, the authors of the study recommended:
1) Men receiving radiation therapy only should wait 12 months before trying to conceive
2) Men receiving >2 cycles of platinum-based chemotherapy should wait 24 months before trying to conceive
No recommendations could be made for men receiving 1-2 cycles of platinum-based chemotherapy due to the small number of patients who received this regimen in the study. At the above recommended cut-offs, the mean sperm aneuploidy rates were back to pre-treatment levels, but at 24 months, 56% of the >2 chemotherapy cycle group and 39% of the radiation-only group still had elevated levels of sperm aneuploidy as compared to age-matched controls, and the clinical significance of this was not known.
Regarding the lymphoma patients, the studies made the following recommendations:
1) Wait to try and conceive for 2 years following treatment with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) or MOPP (mustargen, vincristine, procarbazine, prednisone) regimens.
2) Wait to try and conceive for 1 year following treatment with ABVD (adriamycin/doxorubicin, bleomycin, vinblastine, and dacarbazine)
3) Detection of sperm aneuploidy by FISH (fluorescent in situ hybridization) studies can be performed on cryopreserved sperm (frozen before treatment) or ejaculated sperm after treatment to identify at-risk patients
4) Consider the use of IVF/ICSI + PGS (preimplantation genetic screening) and/or more intensive monitoring of pregnancy if:
a) trying to conceive <1 year following treatment with ABVD
b) trying to conceive <2 years following treatment with CHOP/MOPP
c) using sperm with increase aneuploidy rates (ejaculated or cryopreserved)
As with the testicular cancer study, about 3-6% of the men treated for lymphoma still had elevated levels of sperm aneuploidy at 24 months. Both studies recommended strong consideration of sperm banking prior to starting chemotherapy (despite the risk of increased aneuploidy rates in these pre-treatment sperm).
For more information on the impact of cancer and cancer therapies on male infertility, please click on the following link on the Male Infertility Guide website:
https://www.maleinfertilityguide.com/cancer-and-male-fertility